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RPD-41295

New Mexico Taxation and Revenue Department

Rev. 03/2005

Application for New Mexico Retail Food Store Certification

for the food deduction pursuant to Section 7-9-92 NMSA 1978

Print your company’s name

FEIN or SSN

Print store name and chain unit number if applicable

CRS identification number for store

PART 3 - STAPLE FOOD STOCK

Complete either Section A or B using the terms defined in the instructions.

Section A: Firms that carry a full line of groceries - Complete this part if your store stocks on a continuous basis an ample

variety of the types of foods listed below in each category.

Check “Variety” for each staple food category you sell in your store which meets the definition of variety (see instructions).

Also, check “Perishable” for each category which meets the definition of perishable (see the instructions).

Staple Food Category Examples of staple food items

Variety

Perishable

Bread/Cereals

Bread, cereals, pasta, grains, rice, flour

Dairy Products

Cheese, butter, milk, yogurt

Fruits/Vegetables

All forms of fruits, vegetables, 100% juice

(Include fresh, frozen and canned)

Meat/Poultry/Fish

Beef, chicken, bacon, ham, shellfish, sandwich meats

(Include fresh, frozen and canned)

Section B: Firms with a specialty line of Staple Foods - Check the box below if your business sells a limited variety or line of

staple foods; for example, a bakery, milk route, produce stand or meat market. Stores selling only accessory foods do not

qualify. See Qualifying as a “retail food store” in the instructions. Provide the annual retail food sales and the annual gross sales

at this location that you reported for the same time period for Gross Sales in Part 4 (see below) for the past two years. This

may be an estimated figure.

Check if applicable:

I am applying for New Mexico Retail Food Store Certification under Section B.

PART 4 - SALES INFORMATION

Gross sales reporting method: (Circle one)

Actual

Estimated*

*Use estimated ONLY if previous year information is not yet available, or if this is a new store. You may be required to submit actual

figures when available.

Annual retail food sales at

Annual gross sales at

Federal income

this location as reported to the IRS

tax year

for the last two years.

I declare that I have examined this application, including any accompanying schedules and statements, and to the best

of my knowledge and belief, it is true, correct and complete.

Date

Signature of Taxpayer or Agent

Title

Phone

Print name

FOR DEPARTMENT USE ONLY

This application for New Mexico Retail Food Store Certification was reviewed by the New Mexico Taxation and Revenue

Department and was approved.

Name of Certified New Mexico retail food store

Authorized Department Signature

Date of approval

Page 2 of 3

Form Rpd-41295 - Application For New Mexico Retail Food Store Certification For The Food Deduction Pursuant To Section 7-9-92 Nmsa 1978 - 2005 Page 2

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